Until recently, the staff at Deschutes County's Behavioral Health Annex were grieving all too often for people gone too soon.
The severely mentally ill county residents who receive services at the Annex were dying at the rate of nearly one per month. Nationally, life expectancy is roughly 25 years shorter for those with difficult, chronic mental illnesses such as schizophrenia and bipolar disorder than for the general public, said Travis Sammon, supervisor of Deschutes County Behavioral Health's Assertive Community Treatment team. These individuals often grapple with physical health issues in addition to their mental health concerns, and they struggle to navigate the medical system.
“They were really struggling with how can we solve this,” said Mosaic Medical Executive Director Megan Haase, who shared the concern of county staff. “They have very close relationships with their patients and care so much about them.”
To turn this tide, Deschutes County and Mosaic Medical, a regional organization that provides health care to the underserved, decided to create a pilot program. A Mosaic primary-care physician would come once a week to the Annex, where those with mental health issues already visit regularly for counseling and other services. The doctor would build trust with patients, coordinate their care and help connect them with any specialized medical services they need.
Today, what is now called the Deschutes County Behavioral Health-Mosaic Annex Project has grown from roughly six patients a little more than a year ago to about 100.
The physician, Dr. Tina Busby, has convinced five people to quit smoking. She recognized undiagnosed diabetes in one person and is now helping with its management. Only a couple of deaths have occurred since the project began.
The project has been so effective that the two entities are working on expanding it. The goal is to have a Mosaic primary-care doctor on-site five days a week, serving up to 500 patients.
Merging mental health and medical services is a newer concept in health care that in recent years has gained traction.
Mosaic Medical and St. Charles Primary Care clinics, for instance, have psychologists and other mental health professionals stationed within primary-care clinics.
What is different with the Annex Project, Sammon said, is it brings the primary-care services into the world of mental health, an environment the clients already know and trust.
“What we wanted to do is think where is that health care home,” Haase said. “For a lot of patients, it's with their primary care provider. But for this population, it really is the Annex.”
For her part, Busby has worked to fit in these patients' world to build relationships.
“The more patients trust and participate in their care,” Busby said, “the more effective it is.”
Medicine in the Annex
For a person with a severe mental illness, getting medical care can present a challenge.
Making appointments and getting to them can be difficult, Sammon said. So can dealing with the clinic environment. Some people experience severe anxiety or auditory hallucinations.
“Just sitting in a crowded waiting room for 30 to 40 minutes is too long,” he said.
Once in the exam room, some patients don't always communicate well. They might mumble or not be able to talk about their symptoms with clarity. Others require more time to build trust than is often allotted at a clinic.
Then there is making sure the individuals follow their doctors' instructions or take the next recommended steps. Something as simple as a blood test becomes complicated if the person has difficulty making it to the lab or can't be relied upon to fast for 12 hours.
Deschutes County has hired staff, called peer support specialists, who accompany people needing help to their medical appointments and explain instructions.
While it helps, it doesn't completely remedy the challenges.
“A lot of people don't know how to handle people with mental illnesses,” said Patricia von Riedl, a county peer support specialist. “Doctors are not always used to dealing with that population.”
In contrast, medicine unfolds a little differently at the Annex.
Busby works in an office with a laptop and a few simple medical tools. Ronda Jordan, a medical assistant at Mosaic, accompanies her every Tuesday and coordinates the patients.
Some appointments are scheduled, but time is always reserved for drop-ins. People waiting sometimes mingle in the Rainbow Room, a gathering place in the Annex building for a community that faces similar challenges.
A few patients, Busby said, have wanted to meet her before being willing to participate in any discussion about their medical conditions. The county therapists also sometimes come to the appointments to make the individuals more comfortable.
Busby usually spends more time with each patient than she would at the clinic. She gets to know their stories as well as their medical issues.
A number of them do have medical conditions that require monitoring such as diabetes, chronic obstructive pulmonary disease and high cholesterol. Their management might be more complex depending on their various medications.
Busby said it can take time to convince people to get the care they need. For instance, if she believes a patient's sleep issues merit an assessment that requires dozing off in a lab, she might talk about that over the course of several appointments.
“I give them time to process it to make sure they understand,” she said.
When she does make such referrals, Busby also makes an effort to coordinate with the specialist. She will contact the office ahead of time so they're aware of the patient's mental illness, and she makes it clear that the specialist is welcome to call her for follow-up information.
One positive that quickly emerged from the project was better communication among care providers.
With county therapists, the county psychiatrist and Busby under one roof, information about clients gets shared. They pop into each other's offices to ask questions.
The mind and body issues can also be related. For instance, atrial fibrillation, a type of irregular heart beat, is associated with feelings of anxiety.
“It's really hard when you don't work in one office,” Sammon said. “Everyone has a little piece of the picture. It's fragmented.”
Some of the clients like the setup, as well. Albert Mills, 49, of La Pine, said he isn't certain he would be seeking out the care he needs for early emphysema and other issues if it weren't for the Annex Project.
“She just cares about people,” he said of Busby. “She wants to know what's going on and she tells you what's up.”
In the long run, Haase said, ensuring access to primary care for this population will keep them out of emergency situations, which drives down health costs overall.
Launching the project didn't require a cash infusion, she added. Some of the Deschutes County's clients already came to Mosaic Medical's clinics, so the big difference was changing the setting.
Scott Johnson, director of Deschutes County Health Services, said in an email that the expansion of the Annex Project is one of the department's highest budget priorities for the coming year. The county is presently doing a feasibility study that includes a proposed remodel of the building where the Annex Project is located.
Ultimately, the effort will help better care for an already vulnerable population.
“This is a group of people with a lot of skills and joys,” Busby said. “They deserve to be cared for and respected.”